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In the United States, an estimated 260,000 people have received HCV treatment in 2015. This significant
treatment volume was mostly due to large uptake of patients with advanced liver fibrosis who had been wait-
ing for DAAs to become available [184] . Progress estimates towards elimination in the US are greatly impacted
by significant increases in HCV incidence experienced from 2011 (16,000 new cases) to 2014 (31,000 new
cases), largely driven by the opioid epidemic [185] . Assuming that the rates of new infection remain the same
in the next 14 years, the US can only achieve WHO targets by 2030 if it expands screening to diagnose 80%
of individuals infected (50% of infected individuals are diagnosed at baseline), provides unrestricted treat-
ment for all, and maintains the number of treated patients at least 150,000 per year [184,186] . The Veterans Af-
fairs Health System has taken on robust efforts to increase funding, negotiate reduced costs per cure, screen
the majority of patients at risk, expand treatment capacity by utilizing primary care and pharmacy services
and have offered unrestricted treatment to 75% their patients in need [187] . In coordination with the Center for
Disease Control and Prevention and the Viral Hepatitis National Plan, multiple ongoing federal and non-
federal initiatives take on similar efforts to make a dent in local HCV epidemics across the US [188] .

In 2016, roughly 40,000 Egyptians died of the disease, and nearly 4.5-5 million are currently infected - the
highest burden in the world for Egypt’s population size [189] . Following successful negotiations between gov-
ernment and drug makers in 2014, DAAs have become widely available at markedly reduced prices. Since
then, more than a million Egyptians have been treated [190] . In addition to lowering the cost of drugs, Egypt
has succeeded in opening new treatment centers, creating electronic portals to enroll patients, and expand-
ing its domestic pharmaceutical industry to ensure a steady pipeline of affordable medications [191] .

Georgia, another country with high HCV prevalence, initiated in April 2015 the world’s first program to
eliminate hepatitis. With technical assistance from Centers for Disease Control and Prevention (CDC) and
key partnership with drug industry to provide DAAs free of charge, the ambitious goal was defined as a 90%
reduction in HCV prevalence by 2020 [192,193] . From April 2015 through December 2016, a total of 27,595 per-
sons initiated treatment for HCV infection, among whom 19,778 (71.7%) completed treatment. The number
of persons initiating treatment peaked in September 2016 at 4,595 and declined during October-December.
Broader implementation of interventions that increase access to HCV testing, care, and treatment for per-
[194]
sons living with HCV are needed for Georgia to reach national targets for the elimination of HCV . Brazil,
with an estimated burden of 657,000 people infected, and enhanced DAA access through public health sys-
tem able to negotiate 90% cost reduction in drug prices, hosted the World Viral Hepatitis Summit in 2017,
and presented care cascade estimates that places the country on track of disease elimination by 2030, along
with Australia, Egypt, Georgia, Germany, Iceland, Japan, the Netherlands and Qatar [195] . Taken together,
these examples suggest that the largest hurdle to eliminating HCV is the cost of medications, impeding ac-
cess to therapy in locations where the cost of drugs remains prohibitively expensive.

SURVEILLANCE, ADVOCACY AND POLICY GAPS
As mentioned above, political will to optimize DAA treatment access and reduce costs per cure has been
a main driver for the witnessed public health progress. However, much more needs to be accomplished to
ensure that the hepatitis treatment goals are reached on a global level. Currently, treatment priorities aim
to improve outcomes for individuals with more advanced disease progression. This treatment prioritization
aimed at the individual-level misses the opportunity to reduce incident infections at the population level
through treatment as prevention aimed at individuals largely driving new infections (i.e., PWID). Treatment
prioritization for those with severe liver disease is supported by cost-effectiveness analyses that exclusively
accounts for individual health benefits of HCV treatment. These analyses show that treatment of moderate
to severe disease is cost-effective but, at high HCV treatment costs, treatment of mild disease should be de-
layed [196] . However, due to the relatively long duration of HCV disease progression compared with durations
of risk behavior (such as injecting drug use), treatment of those with advanced liver disease is unlikely to
have prevention benefit [197] . On the other hand, models of HCV transmission that incorporate both indi-